Summary
Background
80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.
Methods
This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with
ClinicalTrials.gov
,
NCT03471494
.
Findings
Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.
Interpretation
Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.
Funding
National Institute for Health Research Global Health Research Unit.
Background: Pilonidal sinus (PNS) is a common disorder that mainly affects young adults. It can be asymptomatic or presented by discomfort, inflammation, abscess or sinus formation. Despite current advances in surgical techniques, the best option to treat PNS is not yet well defined. Many studies reported techniques that involved excision of the sinus and closure of the deep and superficial layers but leaving the skin open. Aim: We aim to compare between the excision and primary midline closure with suction drain versus the partial closure technique as treatment options for PNS in terms of recovery, wound complications and recurrence rate. Patients and Methods: A prospective comparative study at Ain Shams University Hospitals that included 80 patients with PNS was conducted from January 2018 to June 2019. They were divided randomly into group A; 40 patients that had the midline closed method with suction drain and group B; 40 patients that underwent the partial closure technique. Both groups were followed up for 1 year, detecting healing time, wound complications, return to usual activities and recurrence rate. Results: We detected significant differences between both groups as regards to pain and discomfort postoperatively, favoring the partial closure group. Mean time to wound healing was significantly shorter among group A (14.43 ± 3.13) though mean time of return to usual activities was faster among the partial closure group (14.45 ± 1.15). There were no statistically significant differences between both groups as regards to wound infection, dehiscence or hematoma formation. Wound seroma was more among group A.
Conclusion:The partial midline closure technique showed comparable results to the closed method with suction drain in management of PNS disease. Indeed, it shows less postoperative complications and a faster return to usual daily activity. Yet, more studies are required to demonstrate its reproducibility.
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